Provider Demographics
NPI:1164092433
Name:DESTEFANO, NICOLE (BCBA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DESTEFANO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 DARBY CT
Mailing Address - Street 2:
Mailing Address - City:HUMMELSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17036-7202
Mailing Address - Country:US
Mailing Address - Phone:914-552-8250
Mailing Address - Fax:
Practice Address - Street 1:200 BENT CREEK BLVD
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-1938
Practice Address - Country:US
Practice Address - Phone:570-802-3099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-21-48422103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst